Activity:

First Name

Last Name

Location of Activity:

Activity may include:

Date of Activity:

Time of Activity:

Child’s name:

Age:

Parent’s name:

Emergency Phone Number:

Special Information

My child: (check applicable boxes)

Has no existing medical conditions that would endanger him/her from participating.

Has a medical condition that is being treated and poses no danger to his/her participation.

Is taking prescribed medication(s)

Other:

If other, please explain:

By signing below, the parent/guardian gives consent to the said child to participate in a church sponsored activity. The undersigned agrees to hold harmless (which means to not assign blame or legal responsibility) the Lake Hills Baptist Church, its officials and those workers assisting in the activity from any and all harm that may be sustained as a result of or during the activity, including transportation to and from the activity. Parent further agrees to resolve any dispute arising from any harm where the matter is, by mutual consent, deemed not covered by this consent or over the consent itself, by submission to binding arbitration.

Please enter your digital signature:

Date:

Our Services

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